Comprehensive Overview of Psychopathology, Differential Diagnosis, and the DSM-5

TMH Professionals, LLC, American College of Psychotherapy & LPCA present PSYCHOPATHOLOGY, DIFFERENTIAL DIAGNOSIS, AND THE DSM-5: A COMPREHENSIVE OVERVIEW Module 6: Differential Diagnosis, Scope of Practice, and the Addressing of Obsessive-Compulsive and Related Disorders, Dissociative Disorders, and Trauma and Stressor Related Disorders

Your Presenters Naveen Thomas, MD Naveen Thomas, MD, MPH Psychiatrist in Private Practice Azure for Health and Human Services, LLC Wayne Hulon, MDiv, LPC, AAPB Pres., CEO, American College of Psychotherapy Psychotherapy & Neuroscience Charlie Safford, LCSW President,yourceus.com, Inc.

Course Objectives Upon completion of this program trainees will: - Learn the etiology of obsessive-compulsive and related disorders based on current research - Comprehend the complexities of diagnosis for this disorder - Grasp appropriate assessment processes for determining obsessive-compulsive and related disorders, role clarification and differentiation for master’s level clinicians, and appropriate referrals to other professionals in establishing obsessive-compulsive and related disorders diagnoses - Comprehend differential diagnosis from other disorders with similar presentations - Apply common specifiers for obsessive-compulsive and related disorders - Learn appropriate treatment strategies based upon diagnosis

Course Objectives Upon completion of this program trainees will: - Learn the etiology of dissociative disorders based on current research - Comprehend the complexities of diagnosis for this disorder - Grasp appropriate assessment processes for determining dissociative disorders, role clarification and differentiation for master’s level clinicians, and appropriate referrals to other professionals in establishing dissociative disorders diagnoses - Comprehend differential diagnosis with other disorders with similar presentations - Apply common specifiers for dissociative disorders - Learn appropriate treatment strategies based upon diagnosis

Course Objectives Upon completion of this program trainees will: - Learn the etiology of trauma and stressor related disordersbased on current research - Comprehend the complexities of diagnosis for this disorder - Grasp appropriate assessment processes for determining trauma and stressor related disorders, role clarification and differentiation for master’s level clinicians, and appropriate referrals to other professionals in establishing trauma and stressor related disorders diagnoses - Comprehend differential diagnosis with other disorders with similar presentations - Apply common specifiers for trauma and stressor related disorders - Learn appropriate treatment strategies based upon diagnosis

Purposes Behind Diagnosis Accurate diagnosis allows for consistency and standardization throughout all disciplines that address mental health concerns: medical, nursing, psychiatric, psychological, counseling, social work, marriage and family therapy Accurate diagnosis allows for common ground to be established in terms of research concerning the effectiveness of various kinds of treatment Accurate diagnosis can be used for shaping the client's treatment plan, aligning the treatment approaches research has determined to be most effective with the various diagnostic categories

Boundaries around Assessment: Who Makes the Diagnosis for Complex Disorders?

Ethics in Tools and Assessment • What are the legal and ethical boundaries for Master’s level clinicians? • How do we differentiate, ethically and legally, the diagnostic criteria in assessment? • When do we refer for further testing and diagnostics? • To whom do we refer for further assessment?

GA Composite Board states: Rule 135-7-.05. Assessment Instruments (c) Using unsupervised or inadequately supervised test-taking techniques with clients, such as testing through the mail, unless the test is specifically self-administered or self-scored. (d) Administering test instruments either beyond the licensee’s competence for scoring and interpretation or outside of the licensee’s score of practice, as defined by law;

From the Social Work Code of Ethics 1.04 Competence (a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

Psychological Testing by Law O.C.G.A. 377 states: “‘Psychological testing’ means the use of assessment instruments to both: • Measure mental abilities, personality characteristics, or neuropsychological functioning; and • Diagnose, evaluate, classify, or render opinions regarding mental and nervous disorders and illnesses, including, but not limited to, organic brain disorders, brain damage, and other neuropsychological conditions.”

Determining Your Educational Eligibility

Qualifications for Ordering Tests • Qualification Level A: There are no special qualifications to purchase these products • Qualification Level B: Tests may be purchased by individuals with: • A master’s degree in psychology, education, occupational therapy, social work, counseling, or in a field closely related to the use of the assessment, and formal training in the ethical administration, scoring and interpretation of clinical assessments (www.pearsonclinical.com)

Qualification Level B, cont’d OR - Certification by full or active membership in a professional organization that requires training and experience in the relevant area of assessment OR • A degree or license to practice in the healthcare or allied healthcare field OR - Formal, supervised mental health, speech/language, occupational therapy, social work, counseling, and/or educational training specific to assessing children, or in infant and child development, and formal training in the ethical administration, scoring and interpretation of clinical assessments.

Licensure or certification to practice in your state in a field related to the purchase. OR - Certification by or full active membership in a professional organization (such as APA, NASP, NAN, INS) that requires training and experience in the relevant area of assessment.

Qualification Level C • Tests with a C qualification require a high level of expertise in test interpretation, and can be purchased with: • A doctorate degree in psychology, education, or closely related field with formal training in the ethical administration, scoring, and interpretation of clinical assessments related to the intended use of the assessment. OR

Certification by or full active membership in a professional organization (such as APA, NASP, NAN, INS) that requires training and experience in the relevant area of assessment. • EXAMPLE: Minnesota Multiphasic Personality Inventory – 2 www.pearsonclinical.com

Understanding 135-12-.01 and 135-12-.02 and Their Implications

GA Composite Board Rule 135-12-.01 (5) The use of these testing and assessment instruments (a) By persons licensed as Professional Counselors, Social Workers, or Marriage and Family Therapists may include, but is not limited to, administering and interpreting educational and vocational tests; functional assessments; interest inventories; tests that evaluate marital and family functioning; and mental health symptom screening and assessment instruments that evaluate emotional, mental, behavioral, and interpersonal problems or conditions including substance abuse, health, and disability, provided that the use of these instruments does not include rendering a diagnosis or a mental or nervous disorder or illness, including but not limited to organic brain disorders, brain damage, or other neuropsychological functioning or conditions, and provided that the licensee has obtained university level training or substantially equivalent supervised experience in the use of the test or assessment instrument.

(b) By persons licensed as a Professional Counselor may also include other assessments or tests which the licensee is qualified to employ by virtue of his or her education, training, or experience, provided that the use of these instruments does not include rendering a diagnosis or a mental or nervous disorder or illness, including but not limited to organic brain disorders, brain damage, or other neuropsychological functioning or conditions.

135-12-.02 Diagnosis (a) Persons licensed as Professional Counselors, Social Workers, or Marriage and Family Therapists who comply with this section shall be authorized to diagnose and treat mental, emotional, and behavioral disorders through the use of current classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and/or the International Classification System of Diseases and Related Health Problems (ICD).

Section One Assessment and Diagnosis of Obsessive-Compulsive and Related Disorders

Key Changes from DSM-IV-TR to DSM-5

New Diagnostic Terms and Categories Added in the DSM-5 • Hoarding Disorder (ICD-9: 300.3; ICD-10: F42) • Excoriation/Skin Picking, Disorder (ICD-9: 698.4; ICD-10: L98.1)

New Diagnostic Terms and Categories Added in the DSM-5 • Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (ICD-9: 292.89; ICD-10: F14.xxx and F15.xxx) • Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (ICD-9: 294.8; ICD-10: F06.8) These diagnoses should be made by qualified medical and psychiatric personnel only

New Diagnostic Terms and Categories Added in the DSM-5 • Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (ICD-9: 292.89; ICD-10: F14.xxx and F15.xxx) Examples: L-Dopa induced obsessive-compulsive behavioral effects, including uncontrollable gambling or sexual behaviors for Parkinson’s patients or cocaine induced scratching, skin picking and hair pulling due to the disruption of the neurotransmitters at specific brain sites associated with obsessive and compulsive behaviors. For the diagnosis to be used properly, the obsessive or compulsive symptoms must appear during or soon after substance intoxication or withdrawal for drugs, and after exposure for a medication. It must also cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. These diagnoses should be made by qualified medical and psychiatric personnel only

New Diagnostic Terms and Categories Added in the DSM-5 • Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (ICD-9: 294.8; ICD-10: F06.8) Example: Obsessive-compulsive and related disorder due to cerebral infarction. If this condition is noted, it will be accompanied with the specifiers that clarify how the OCD behaviors are appearing. These are the options that will likely be noted: • With obsessive-compulsive disorder-like symptoms (Akin to symptoms of OCD, e.g., hand washing, ritualistic behaviors) • With appearance preoccupations (Akin to body preoccupation as in Anorexia or Bulimia Nervosa) • With hoarding symptoms (Akin to symptoms of Hoarding Disorder which has been added as a diagnosis in the DSM-5) • With hair-pulling symptoms (Akin to symptoms of trichotrillomania) • With skin-picking symptoms (Akin to symptoms of Skin-Picking Disorder which has been added as a diagnosis in the DSM-5) These diagnoses should be made by qualified medical and psychiatric personnel only

Important Reformulations of Diagnoses in the DSM-5 • Obsessive-Compulsive and Related Disorders 1) A new specifier, “With poor insight”, has been added in the DSM-5 to allow for more subtle distinctions concerning degrees of insight about OCD beliefs held by clients. In the DSM-IV-TR, the only two choices were “good or fair insight” and “absent insight/delusional”.

Assessment Components for Diagnosis of Obsessive-Compulsive and Related Disorders

Gathering Information During Assessment of Obsessive-Compulsive and Related Disorders All components of a thorough biopsychosocial assessment should be addressed Gather present and past history of stresses, traumas, violence and abuse Careful gathering of the client’s history of obsessive and compulsive behaviors and thoughts, present and past Family history of problems with obsessive and compulsive behaviors, mental illness, or traumatic events Gather medical history – illness and injury, history of use of medications, nutritional supplements, toxic substance exposure Use of screening tools specifically designed to uncover presence of obsessive and compulsive behaviors and thoughts

Symptoms to Look for in Assessment of Obsessive-Compulsive Disorders 1.

Symptoms to Look for in Assessment of Obsessive-Compulsive Disorders Obsessions Unwanted, repetitive and intrusive ideas, urges or images. Persistent paranoid fears, an unreasonable concern with becoming contaminated, or an excessive need to do things perfectly. Compulsions Repetitive behaviors, or compulsions. The most common of these are putting things in order, checking, and washing. Other compulsive behaviors include rearranging, counting (often while performing another compulsive action such as lock-checking), mentally repeating phrases, list making, and avoiding.

Screening Tools Used in Assessment of Obsessive-Compulsive Disorders Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) Florida Obsessive-Compulsive Survey

Core Problems of Obsessive-Compulsive Disorders Research suggests that OCD involves problems in communication between various structures of the brain, including elevated brain activity in areas of the frontal lobes (particularly the orbital cortex) and the basal ganglia with disruptions in one or more neurotransmitters, specifically serotonin and dopamine. According to one model, the basal ganglia and its connections are turned on inappropriately in OCD, with over-activity in its neurotransmitter receptor sites. Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in patients with OCD. There appears to be a connection between the OCD symptoms and abnormalities in certain areas of the brain, but that connection is not clear.

Core Problems of Obsessive-Compulsive Disorders Many investigators have contributed to the hypothesis that OCD involves dysfunction in a neuronal loop running from the orbital frontal cortex to the cingulate gyrus, striatum (cuadate nucleus and putamen), globus pallidus, thalamus and back to the frontal cortex. Insel has proposed that inappropriately increased activity in the head of the caudate nucleus inhibits globus pallidus fibers that ordinarily dampen thalamic activity. The resulting increase in thalamic activity produces increased activity in orbitofrontal cortex, which, via the cingulate gyrus, completes the circuit to the caudate and produces increased activity in the head of the caudate. Hypothetically, primitive cleaning and checking behaviors are "hard-wired" in the thalamus.

Core Problems of Obsessive-Compulsive Disorders Baxter et al. in 1992 hypothesized that the hyperactivity observed in this neuronal loop arises because of impaired caudate nucleus function. The impairment allows "worry inputs" from the orbitofrontal cortex to inhibit excessively the inhibitory output from the globus pallidus to the thalamus. The resulting excess in thalamic output then impinges on various brain regions involved in the experience of OCD symptoms, including the orbital frontal region, thus reinforcing hyperactivity in the neuronal loop. In brief, the theory is that the caudate nucleus doesn’t function properly and causes the thalamus to become overactive, in which case it sends never-ending worry signals between the Orbital Frontal Cortex and the thalamus. The OFC responds by increasing anxiety.

Core Problems of Obsessive-Compulsive Disorders Researchers are looking at deeper levels of brain functioning to see how genetic factors may contribute to the development of OCD. In particular, researchers are looking at the contributions of various protein factors that may contribute to the neurotransmitter dysfunctions at the core of OCD. There are also other potential avenues that may lead to the development of OCD, including possible neurological damage from head injuries or bacterial infections that cross the blood-brain barrier, most notably a streptococcal infection, resulting in a type of OCD called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS).

Core Elements of Successful Treatment of Obsessive-Compulsive Disorders Psychotherapy for Obsessive-Compulsive Disorders generally consists of: Cognitive behavioral therapy (CBT), and/or Exposure and Response Prevention (ERP), Antidepressants approved by the Food and Drug Administration (FDA) to treat OCD include: Clomipramine (Anafranil) for adults and children 10 years and older Fluoxetine (Prozac) for adults and children 7 years and older Fluvoxamine for adults and children 8 years and older Paroxetine (Paxil, Pexeva) for adults only Sertraline (Zoloft) for adults and children 6 years and older

Core Elements of Successful Treatment of Obsessive-Compulsive Disorders For clients with intractable OCD symptoms not responsive to other modes of treatment, neurosurgery is sometimes performed to sever connections between areas of the brain whose over-activity is responsible for ongoing OCD effects.

Neuroanatomy and Obsessive-Compulsive Disorders

Key Differential Diagnosis: OCD versus Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive and Related Disorders Criteria: Presence of obsession, compulsions, or both: Obsessions are defined by (1) or (2) 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Obsessive-Compulsive and Related Disorders Compulsions are defined by (1) or (2) 1. Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to behaviors or mental acts are aimed at preventing or reducing anxiety or distress; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly obsessive. B. The obsessions or compulsions are time-consuming and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Obsessive-Compulsive and Related Disorders C. The obsessive-compulsive symptoms are not attributable the physiological effects of a substance or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder. Specify if: With good or fair insight With poor insight With absent insight/delusional beliefs Tic related

Personality Disorders Criteria: A. A pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2. Shows perfectionism that interferes with task completion 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships 4. Is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).

Personality Disorders Criteria: A. A pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value. 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. Shows rigidity and stubbornness

Other Obsessive-Compulsive and Related- Disorders

Obsessive-Compulsive and Related Disorders Criteria: Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Obsessive-Compulsive and Related Disorders Specify if: With muscle dysmorphia-The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. Indicate degree of insight regarding body dysmorphic disorder beliefs: With good or fair insight- The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight- The individual thinks that the body dysmorphic disorder beliefs are probably true. With absent insight/delusional beliefs- The individual is completely convinced that the body dysmorphic disorder beliefs are true.

Comprehensive Overview of Psychopathology, Differential Diagnosis, and the DSM-5